Disclosures: Nicole Diaz-Segarra, MD: No disclosure data submitted.

Case Description: Paradoxical response to administration of zolpidem

Setting: Acute Rehabilitation

Patient: A 36-year-old post-partum female presented 10 days after an uncomplicated C-section with severe headache and confusion. Head imaging showed a frontal lobe hemorrhage with midline shift requiring an emergent craniectomy. Once stabilized, she was transferred to rehabilitation on day 30 in a minimally conscious state (MCS).

Assessment/Results: She was maintained on methylphenidate and bromocriptine for neuro-stimulation. Her neurologic status remained unchanged and zolpidem 10 mg every morning was initiated on day 43. Within 24 hours, she demonstrated an improved level of arousal and ability to answer yes/no questions accurately. These improvements persisted after stopping zolpidem and she emerged from MCS on day 54. Her cognition and functional status continued to improve, and she underwent cranioplasty on day 92. At one-year post-injury, she communicates independently and has regained most of her cognitive faculties.

Discussion: Zolpidem is a non-benzodiazepine sedative-hypnotic medication that selectively binds to omega-1 γ-aminobutyric acid (GABA) receptors and is FDA approved for insomnia treatment. There are reports of off-label zolpidem use for a paradoxical transient stimulatory effect in severe brain injury patients with disorders of consciousness. These “responders” are postulated to have increased metabolism in the anterior forebrain mesocircuit, specifically the striatum, globus pallidus, and thalamus, resulting in improved level of arousal, communication, and transient emergence. While the transient effect after administration has been documented, the potential impact on long-term outcomes and persistent emergence remains unclear.

Conclusion: This case demonstrates dramatic improvement in neurologic function after the administration of zolpidem in a patient with a severe brain injury. While natural recovery cannot be excluded, this patient’s response highlights the possible utility of zolpidem in assisting with sustained consciousness and positive long-term outcomes. Clinicians should consider the off-label use of zolpidem in patients whose neurologic status does not improve with traditional neuropharmacology.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2019

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/paradoxical-response-to-administration-of-zolpidem-in-a-severe-acquired-brain-injury-a-case-report/